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15-Minute Visits Take A Toll On The Doctor-Patient Relationship

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“Doctors are thinking, ‘I have to meet my bottom line, pay my overhead, pay my staff and keep my doors open. So it’s a hamster wheel, and they’re seeing more and more patients … And what ends up happening is the 15-minute visit,” he said.

Struggling For Control

Dr. Richard J. Baron, president of the American Board of Internal Medicine, said that patients and physicians often wrangle over control of that visit – a “struggle for control” over the allocation of time

Sometimes the struggle is overt – as when a patients pulls out a long list of complaints as soon as the doctors comes in.

Sometimes, it’s more subtle. When Judy Weinstein went to see her doctor in Manhattan recently, she knew she would get only 20 minutes with him – even though it was an annual physical, and she had waited nine months for the appointment.

So when the doctor asked if he could have a medical student shadow him, she put her foot down.

“I said, ‘Y’know, I would prefer not. I get 20 minutes of your divided attention as it is – it’s never undivided, ever – and I need to not have any distractions. I need you focused on me.’“

How did visits get so truncated? No one knows exactly why 15 minutes became the norm, but many experts trace the time crunch back to Medicare’s 1992 adoption of a byzantine formula that relies on “relative value units,” or RVUs, to calculate doctors’ fees.

If you must know, the actual formula is: (Work RVU x Geographic Index + Practice Expenses RVU x Geographic Index + Liability Insurance RVU x Geographic Index) x Medicare Conversion Factor.

That was a switch for Medicare, which had previously paid physicians based on prevailing or so-called usual and customary fees. But runaway inflation and widespread inequities dictated a change. RVUs were supposed to take into account the physician’s effort and cost of running a practice, not necessarily how much time he or she spent with patients. 

The typical office visit for a primary care patient was pegged at 1.3 RVUs, and the American Medical Association coding guidelines for that type of visit suggested a 15-minute consult.

Private insurers, in turn, piggybacked on Medicare’s fee schedule, said Princeton health economist Uwe Reinhardt. Then, in the 1990s, he said, “managed care came in and hit doctors with brutal force.”

Doctors who participated in managed care networks had to give insurers discounts on their rates; in exchange, the insurers promised to steer ever more patients their way.

To avoid income cuts, Reinhardt said, “doctors had to see more patients – instead of doing three an hour, they did four.”

Rushed Doctors Listen Less

How doctors structure the precious 15-minute visit varies – often quite dramatically.  Generally, they start by asking the patient how they are and why they came in, trying to zero in on the “chief complaint” -- the medical term for the patient’s primary reason for the visit.

Fri, Apr 18 2014

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